Follow up

Follow up Intervals

Post operatively patients are usually seen at 6 to8 weeks initially, unless there is a specific concern when they are seen earlier.

3, 6, 9, 12, 18 and 24 months then yearly

All patients have  a plain CXR and are weighed

The role of CXR is debated, points to look for include effusions, pulmonary metastasis, and increased mediastinal contour indicating recurrent mediastinal disease. an increased size of gastric tube can indicate gastric outlet obstruction secondary to inadequate or lack of adequate pyloromyotomy or recurrent carcinoma.

What you ask patient

How they feel. 

How they feel is very important as feeling lousy or constantly tired is often the first sign of recurrent disease.

Appetite, weight loss and dysphagia. 

It is usual to loose weight in the first 8 weeks

Loss of appetite and metallic sense of taste again may indicate recurrent disease.

Weight loss again can indicate recurrent disease.

Dysphagia may indicate either a benign anastomotic stricture or recurrent disease, endoscopy and biopsy is the only option here.

Symptoms of reflux and regurgitation

Symptoms of reflux are common post operatively. Anti acid therapy is often very helpful.

Regurgitation and vomiting of food can occur. Patients should be questioned about meal size and frequency, and adjusted as necessary. If any concern exists a barium swallow can be more helpful than endoscopy in this setting.

Pain

Abdominal pain can be caused by virtually anything, obviously dumping syndrome and recurrent disease are high on the list after an oesphagectomy.

Bone pain. This is common at the site of the thoracotomy. The important point in the history is was the pain present immediately after the operation and failed to go away, or is it a new pain that keeps you awake at night. A bone scan can help here. Non steroidal anti inflammatory drugs can be very helpful.

Wound problems

Wounds can get infected early or late. Tumour recurrence should always be thought about in late cases.

Always think anasotomosis leak, this is usually associated with a pleural effusion and is usually obvious.

They are especially occurs especially in poorly opened and closed cases, cases that bleed excessively and in patients re-operated on for anasotomotic leaks

Exercise tolerance

This is quite often reduced post operatively for a number of reasons, and is a common complaint

Poor nutrition

Prolonged hospital stay - usually means a post operative complication of some type

Recurrent carcinoma

Left lung affected by left thoracotomy, adhesions and post operative diaphragmatic function post phrenotomy

Chemotherapy and radiotherapy induced pulmonary injury

Recurrent aspiration

Barium swallow verses CT scan for recurrent disease

If the main problem is dysphagia then OGD ? biopsy is the thing to do, barium swallow allows a subjective assessment of the degree of gastric emptying in cases of gastric atonia and pyloric obstruction secondary to an incompletely performed pyloromyotomy or when one has not been performed

CT scanning is good for assessing extraluminal recurrent disease eg pulmonary mets, liver mets, and  mediastinal recurrence

Tracheoesophageal fistula

This usually presents with recurrent chest infections, chronic cough or severe respiratory compromise

In upper third and mid third tumours the possibility of developing a tracheoesophageal fistula should not be forgotten

Recurrent disease causing tracheooesophageal fistula will not heal with radiotherapy or chemotherapy to the recurrent disease. A covered stent is needed, variation in opinions occur  in whether an oesophageal or tracheal or both are deployed

New onset or increasing pleural effusions

New effusions new effusions are usually due too recurrence samples should always be sent for cytology and culture and biochemistry.

Chyle leaks and anastomosis leaks secondary to recurrence can occur late

Recurrence

If any concerns about recurrence exist there are really only two options in relatively asymptomatic patients. these are endoscopy (usually normal in absence of dysphagia) and CT scan of thorax and abdomen. Bone scans and PET scans utilising 6 Fluordeoxyglucose may prove useful in the future.

Treating recurrent disease

Recurrence can be treated by 

Watching and waiting if the patient has no symptoms

Radiotherapy

Chemotherapy

Stenting if dysphagia is a problem

Repeated dilation for slow growing tumours

INVOLVE THE ONCOLOGISTS / PALLIATIVE CARE TEAM AND MACMILLAN NURSES